in network at employer, cash only in private practice - how does it work?

[MaleficentGolf0]

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Hi everyone!

I'm a psychiatrist in NJ.

I'm credentialed and in network with Medicare and commercial insurors at my employer - a large medical center.

I would like to open a small cash only private practice on the side.

How can I make this work without inadvertently committing insurance fraud?

I've called a few insurance companies to figure this out and have received answers from "when you are in network with us, you are in network throughout the state" to "I don't know."

I've talked to health care attorneys and have received answer from "It's not legal" to "If it's a different physical address, you are fine, don't worry"

I'm pretty unclear on how to make this happen, although I know this is a very common set up.

I would really appreciate any guidance.

Thank you!

 

[splik]

I've called a few insurance companies to figure this out and have received answers from "when you are in network with us, you are in network throughout the state" to "I don't know."

it may depend on the arrangement with the insurance company but in general you're only in network with the physical address that you are paneled under with the insurance company. It is usually that institution's tax id under which the contract is with.

With medicare however, you are in or you are out. There is nothing stopping you not seeing medicare pts in your private practice (its probably a little ethically dicey, but its also pretty standard practice in our field) but you must be aware that if a patient has medicare, they cannot pay cash to see you if you are opted in as a medicare provider. and if they lie about it and it turns out they have medicare, you can't charge them and would likely be on the hook for the cost. the exception is if they are seeing you for services not covered by medicare (which it is highly unlikely to be the case).

 

[Sushirolls]

My understanding is private insurance is based upon location. Whatever practice location they have on file gets the renumeration for services at that site. Different location no payment until you get it added, and added with your tax ID / business.

Medicare as Splik pointed out is all or nothing. Well, there is also 'Non-Par', but we'll skip that discussion today. So if you accidentally see a medicare patient and you are paneled with medicare at your employed job, you cannot bill the patient directly, balance bill, etc. And if you do, and Medicare gets wind, you are required to pay the patient back, and possibly somewhere in there is a fee or two, or interest.

I believe Medicaid, and Tricare has a similar setup, too as Medicare.

So it means screen these patients out, which screening has its own issues. Or go to the PECOS website, https://pecos.cms.hhs.gov/pecos/login.do#headingLv1 and explore how to get a separate Medicare number from your Employer, if possible. So if you do see the patients its very clear you get the payment and not accidentally sent to your other employer who at some point you authorized a "reassignment of benefits" i.e. they get your money and not you.

Also look into your employer's contract and see if they have any non-competition clause, or restriction of outside practice. Some contracts may have hour limitations to outside work, or even that they must agree to what you plan to do. If you go behind their back it could be considered a "with cause" termination and be quite hasty with other undesired consequences buried in the contract...

 

[hamstergang]

While the private insurances should be location specific, I do know of cases where insurance made that difficult. They may tell patients that you're in network at your private office and require a good deal of time from you to resolve this.

 

[dl2dp2]

it may depend on the arrangement with the insurance company but in general you're only in network with the physical address that you are paneled under with the insurance company. It is usually that institution's tax id under which the contract is with.

With medicare however, you are in or you are out. There is nothing stopping you not seeing medicare pts in your private practice (its probably a little ethically dicey, but its also pretty standard practice in our field) but you must be aware that if a patient has medicare, they cannot pay cash to see you if you are opted in as a medicare provider. and if they lie about it and it turns out they have medicare, you can't charge them and would likely be on the hook for the cost. the exception is if they are seeing you for services not covered by medicare (which it is highly unlikely to be the case).

This is the correct answer.

However, there are ways around the Medicare limitations by charging a membership fee in your private practice in a particular way. Primary care doctors do this all the time.

 

[dl2dp2]

The best way to get around this is tends not to be possible if you work for an institution that wants you to use your own NPI to bill medicare. but if you work for a group practice, or work for a physician group that contracts to provide services to an institution, you can be opted out of medicare personally, but provide services to medicare patients through a group TIN. MACRA makes it clear it is possible to bill on a per practice basis.

Wow, this is fascinating. I thought CMS regs explicitly is written down to prevent this, but I suppose it's difficult to fully prevent this since very often facilities would require on the fly locums, and billing services rarely check your crendentialing, and credentialing is often incomplete. I just thought typically facilities just eat the cost when claimed are rejected, but I suppose what you say makes more sense. So what I'm confused about then is what's preventing a physician to register a TIN to explicitly use it to create a "group" that would bill Medicare?

Of note, these are loopholes that also creates complications in risk management. For example, let's say you have two work locations, one takes some insurance, one does not, you better hope that your employee's malpractice covers your work at the place that takes insurance, because your private practice malpractice likely only covers worked conducted at that facility.

 

[michaelrack]

For example, let's say you have two work locations, one takes some insurance, one does not, you better hope that your employee's malpractice covers your work at the place that takes insurance, because your private practice malpractice likely only covers worked conducted at that facility.

your malpractice policy will cover whatever locations you add to your policy. If I wanted to, I could get my private malpractice policy to cover my employed position- with $, anything is possible